Nursing Elites

1. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

• A. Building rapport with the child
• B. Taking the child’s temperature
• C. A, D
• D. Obtaining an interpreter if necessary

Correct answer: C

Rationale: Building rapport with the child is essential to establish trust and cooperation during the assessment. Admiring the child may not be appropriate in a professional setting and might not contribute significantly to the assessment. Taking the child's temperature is a routine part of the assessment but may not be the most critical action in this scenario. Obtaining an interpreter is crucial to ensure effective communication between the healthcare team and the child and their mother, especially considering potential language barriers.

2. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

• A. Provide nutrients
• B. Increase protein stores
• C. Elevate the circulating blood volume
• D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Albumin increases the circulating blood volume, which helps to reduce ascites and improve hemodynamics in clients with portal hypertension. Choice A is incorrect because salt-poor albumin is not primarily administered to provide nutrients. Choice B is incorrect because the main purpose of administering albumin is not to increase protein stores but to address fluid shifts. Choice D is incorrect because administering albumin does not divert blood flow away from the liver temporarily; instead, it helps improve blood volume and circulation.

3. Which risk factor would the nurse expect to find in the client diagnosed with pancreatic cancer?

• A. Chewing tobacco
• B. Low-fat diet
• C. Chronic alcoholism
• D. Exposure to industrial chemicals

Correct answer: C

Rationale: The correct answer is C: Chronic alcoholism. Chronic alcoholism is a significant risk factor for pancreatic cancer as alcohol has a damaging effect on the pancreas. Chewing tobacco (choice A) is associated with oral and throat cancers, not specifically pancreatic cancer. A low-fat diet (choice B) is generally considered a healthier choice and not a direct risk factor for pancreatic cancer. Exposure to industrial chemicals (choice D) may be linked to other types of cancers but is not a major risk factor for pancreatic cancer.

4. Which question should the healthcare provider ask when assessing the client for an endocrine dysfunction?

• A. “Have you noticed any pain in your legs when walking?”
• B. “Have you had any unexplained weight loss?”
• C. “Have you noticed any change in your bowel movements?”
• D. “Have you experienced any joint pain or discomfort?”

Correct answer: B

Rationale: The correct answer is B: “Have you had any unexplained weight loss?” Unexplained weight loss can be a significant symptom of various endocrine disorders, such as hyperthyroidism and diabetes. Weight changes are often closely linked to endocrine dysfunction due to the hormonal imbalances affecting metabolism. Choices A, C, and D are less specific to endocrine dysfunction. Pain in the legs, changes in bowel movements, and joint pain or discomfort are symptoms that can be related to various health conditions but are not as indicative of endocrine disorders as unexplained weight loss.

5. A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit?

• A. Crying
• B. Self-mutilation
• C. Immobile posturing
• D. Repetitive activities

Correct answer: C

Rationale: In catatonic schizophrenia, clients commonly exhibit immobile posturing, where they may maintain a fixed position for extended periods. This could include holding rigid poses or remaining motionless. Choice A, 'Crying,' is not typically associated with catatonic schizophrenia. Choice B, 'Self-mutilation,' refers to a different behavior seen in some mental health conditions but is not a characteristic feature of catatonic schizophrenia. Choice D, 'Repetitive activities,' does not align with the typical presentation of catatonic schizophrenia, which is characterized by motor abnormalities such as immobility rather than engaging in purposeful repetitive movements.

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